Gynacological Tumours and Cancers Flashcards
Cervical Intraepithelial Neoplasia
precursor lesion for Cervical Ca; Requires persistent HPV infection to develop; High risk HPV strains include 16, 18, 31 and 33
Transformation Zone
Endocervix comprises thin Secretory Glandular Epithelium which meets the Ectocervix Stratified Squamous Epithelium at the Squamocolumnar Junction
o Under influence of Oestrogen, Glandular Epithelium pushed out into Ectocervix, where due to the lower Ph, undergoes Metaplasia =Transformation Zone
▪ TZ typically Ectocervical in women of reproductive age, while it is Endocervical in Post-menopausal women
o High Mitotic Activity of TZ is vulnerable to HPV-driven change
Dyskaryosis
Cytological Dx – Primary screening tool; Markers include NCR, Shape and Density of Nucleus, Inflammation, Infection or Mitoses
Colposcopy
Magnified Visualisation of TZ after applying 5% Acetic Acid or Lugol’s Iodine
o Abnormalities are Punched Biopsied or definitively treated
If Cancer suspected, do not treat with LLETZ as can cause bleeding, and compromise further treatment
o CIN appears as ‘Acetowhite Epithelium’, with Vascular abnormalities, especially Mosaic and Punctuating; Grossly abnormal vessels suggestive of Microinvasive
CIN
Histological Dx – Characterised by loss of Differentiation and Maturation of Basal Layer; CIN I – III Based on Thickness of abnormality
Management of CIN 1
Spontaneously regresses in 50-60% within 2yrs; Low malignant potential, but 10-fold higher than normal cytology
o Conservative monitoring with Colposcopy/Cytology 6/12ly, or LLETZ if persistent
Management of high grade CIN
High Grade CIN (>I) – Progresses to cancer in 3-5% of CIN II and 20-30% of CIN III within 10yrs;
LLETZ is recommended
Complications of LLETZ
Haemorrhage, Infection, Vaso-vagal Reaction, Anxiety; In longer term, Cervical Stenosis, Incompetence and Risk of Premature Delivery can occur (rarely)
Follow up after LLETZ
If Low grade, Cytology and HPV testing at 6/12; If normal, return to 3yrly; If High grade, Cytology and High-risk HPV Test of Cure at 6/12; if normal, return to 3yrly
NHS Cervical Screening Programme
• Smear Test Screening to pick up CIN, which progresses to Cancer
o 3yrly for women 25 – 50yrs; If normal, then 5yrly between 51 – 64
• If Borderline or Mild Dyskaryosis – Testing for High-risk HPV subtypes
o If High risk subtypes present, or if Abnormal Cytology – For Colposcopy
• If normal Smear – Follow up in 3yrs
Cervical Cancer Stats
Second most common cancer in women worldwide; Mortality decreasing due to Screening
o Dual peaks of incidence 30-39yrs, and >70yrs
o Screening changes disease trend towards Microscopic disease and Adenocarcinoma
Risk Factors for Cervical Cancer
Overwhelming majority associated with Persistent, high risk HPV infection; Other RF include Smoking (reduces viral clearance) and Immunosuppression
Cervical Ca Presentation
Presents at Screening and Treatment of CIN, Post-coital Bleeding, Post-Menopausal Bleeding (Although more likely to be Endometrial Ca); Rarely presents as Vaginal Bleeding, Ureteric Obstruction, Weight loss, Bowel Disturbance and Fistulas (Vesicovaginal most commonly)
Assessment of Cervical Cancer
U/Es, LFTs, FBCs; CT AP for staging; MRI Pelvis; Examination Under Anaesthesia
• FIGO Staging system – Based on Diameter/Size, Involvement of Pelvic Sidewall, Extent of
Vagina, Extension between True Pelvis, Bladder/Bowel Involvement or Distant mets
Treatment of Cervical Cancer: Stage 1a1
Local excision or TAH
Treatment of Cervical Cancer: Stage 1a2 and 1b2
Check for LN involvement with pelvic lymphadenectomy
FZ or Paraffin in two-stage; If LN negative, Wertheim’s Hysterectomy
Treatment of Cervical Cancer: Fertility Sparing Surgery
E.g. Radical Trachelectomy for early stage disease if LN negative
o Increased risk of Late miscarriage, PPROM,
Preterm delivery
Treatment of Cervical Cancer: Stage 1b2 +
Stage Ib2 (>4cm) and IIa (Beyond Uterus) – CRT, Lymphadenectomy and Wertheim’s
• >Ib2 – Combination Chemoradiotherapy
• Stage IVb – Chemotherapy, Radiotherapy, Best Supportive Care, Palliative RT
Ovarian Cancer
Leading cause of death from gynaecological malignancy; 90% Epithelial Ovarian Cancer
o Peak incidence 75 – 84yrs
• Believed to be due to irritation of Surface Epithelium by damage during ovulation;
Risk Factors for Ovarian Cancer
COCP halves risk, Nulliparity, Early Menarche/Late Menopause increases risk
• Genetic Risk – BRCA1, BRCA2, HNPCC (Lynch Syndrome)
o Surveillance with CA125/TVS (Efficacy not proven); Prophylactic surgery (BSO ± TAH)
Mature Cystic Teratoma
Mature Cystic Teratoma (=Dermoid Cyst) – Common benign tumours typically occurring in premenopausal age group; Asymptomatic but rupture is painful
o Teratomas are Germ Cell Tumours which form normal tissue structures
o Most Teratomas contain elements derived from all three Embryonic layers
o Typically, Cystic tumours lined with Skin with Underlying Sebaceous Glands and Hair Follicles; Cyst becomes filled with thick greasy Sebaceous Material and Hair
High Grade Serous Carcinoma
Most common Malignant Ovarian Tumour accounting for 70% of Ovarian Cancers; More commonly Solid and Cystic Components
o Composed of Pleomorphic cells with Hyperchromatic Nuclei with high NCR arranged in a Papillary architecture
High Grade Serous Carcinoma: Risk Factors
Number of Ovulations, Family History (5% Inherited Cancer Syndromes e.g. BRCA1/2 and Lynch Syndrome
o BRCA1/2 have 30-60% Lifetime Risk of developing Ovarian Ca
High Grade Serous Carcinoma: Presentation
Might present with diverse, non-specific signs that only manifest if tumour is large; Pain, Abdominal Swelling, Anorexia, N+V, Weight Loss; Ascites, Pleural Effusion
o Patients usually present at high stage; Poor prognosis
